Category Archives: Most Wanted List

Add a Day of Remembrance for a Balanced Holiday Season

By Chairman Robert L. Sumwalt

Every year, I hear that the holiday season has gotten too long—that holiday music, commercials, and sales begin too early. Traditionally, the season starts on Thanksgiving, the fourth Thursday of November.

 

I think the season should actually start even earlier this year—on the third Sunday in November, World Day of Remembrance for Road Traffic Victims. Why? Because to truly give thanks for what we have, we have to imagine losing it. Around the world, about 1.3 million people lose their lives in automobile crashes every year; 20 to 50 million more survive a crash with injuries, many of which are life-altering. Here in the United States, annual traffic deaths number around 37,000—more than 100 a day—and a motor vehicle crash is the single most likely way for a teen to die.

WDR-Logo-FB

If you’ve lost somebody to a crash, you probably need no special reminder. Your loved one will be missed at the holiday dinner table, on the way to the home of a friend or out-of-town relative, and throughout the holidays. But for the rest of us, the Day of Remembrance is a time to think of those needlessly lost on our roads.

I encourage us all to go beyond remembering those lost in highway crashes, to thinking of victims of transportation accidents in all modes who won’t be joining family and friends this holiday season. Before we give thanks next Thursday, let’s take a moment to remember those who have been lost, and then take steps to make our own holiday travel safer.

By Car

Fatigue, impairment by alcohol and other drugs, and distraction continue to play major roles in highway crashes. Here’s what you can do to keep yourself and those around you safe on the road.

  • If your holiday celebrations involve alcohol, ask a friend or family member to be your designated driver, or call a taxi or ridesharing service.
  • In a crash, seat belts (and proper child restraints) are your best protection. Always make sure that you and all of your passengers are buckled up or buckled in!
  • Make sure to use the right restraint for child passengers, and be sure it’s installed correctly. If you have doubts, ask a Certified Child Passenger Safety Technician.
  • Make sure you’re well rested! A fatigued driver is just as dangerous as one impaired by alcohol or other drugs.
  • Avoid distractions. In this video, survivor-advocates share their stories of personal loss—and the changes they’re working for now.
  • Don’t take or make calls while driving, even using a hands-free device. Set your navigation system before you start driving. If you’re traveling with others, ask them to navigate.

By Bus or Train

We’ve made recommendations to regulators and industry to improve passenger rail and motorcoach operations and vehicle crashworthiness, but travelers should know what to do in an emergency.

  • Pay attention to safety briefings and know where the nearest emergency exit is. If it’s a window or roof hatch, make sure you know how to use it.
  • If you’re unsure of where the exits are or how to use them, or if you didn’t receive a safety briefing, ask your driver or train conductor to brief you.
  • Always use restraints when they’re available!

By Air or Sea

Airline and water travel have become incredibly safe, but these tips can help keep you and your loved ones safe in an emergency.

  • When flying, make sure that you and your traveling companions have your own seats—even children under age 2.
  • Don’t forget your child’s car seat. The label will usually tell you whether your child car seat is certified for airplane use; the owner’s manual always has this information.
  • If you don’t know the rules for using a child’s car seat on your flight, call the airline and ask what you need to know.
  • Pay close attention to the safety briefing! Airline and marine accidents have become very rare, but you and your family can be safer by being prepared.
  • Whether you’re on an airplane or a boat, know where to find the nearest flotation device.

This holiday season, no matter how you plan to get where you’re going, remember that, for many, this time of year is a time of loss. Honor survivors and remember traffic crash victims by doing your best to make sure you—and those around you—make only happy memories on your holiday travels.

Too Close for Comfort in San Francisco

By Bruce Landsberg, Vice Chairman

On March 27, 1977, two Boeing 747s collided on a foggy runway in Tenerife, Spain. The crash took 583 lives, marking it as the deadliest aviation accident in history. Although commercial airline safety has made huge strides since then, a disaster potentially twice as deadly as Tenerife was recently averted by only about 13 feet.

In the late evening hours of July 7, 2017, an Air Canada Airbus A320 inbound from Toronto almost collided with four jetliners awaiting take off at San Francisco International airport (SFO). The night was clear and calm, with no weather to obscure the visual approach to Runway 28 Right.

The Air Canada pilots, not realizing the parallel runway (28 Left) was closed, lined up on a nearby taxiway rather than their assigned runway. As the waiting airliners flashed their landing lights to alert the errant Airbus, one of the pilots on the control tower frequency ground broadcast can be heard saying “Where’s this guy going?” and “He’s on the taxiway!” In the last few seconds, the Air Canada crew recognized their error and aborted the landing.  Simultaneously, the tower controller ordered the Airbus to go around.

Upon landing, the captain called the tower to discuss the incident, and then went to bed. It was 3 am by his body clock and he was exhausted. Although he was required to do so as soon as possible, the captain did not inform Air Canada’s dispatcher about the incident until 16 hours later, by which time the aircraft had already departed on a morning flight, resulting in the required 2-hours of cockpit voice recorder (CVR) data being overwritten.

With all the equipment, training, and safety management systems implemented since Tenerife, it’s astonishing how a near miss like this could happen. But as our investigation revealed, a long and intricate chain of events was to blame. We clearly understand now what happened, but, because the CVR data was lost, we only know part of the why.

We made several recommendations to address the safety issues our investigation uncovered. The incident report, which is available at ntsb.gov, should be required reading for pilots of both large and small aircraft. Here are some of the most important takeaways.

Knowing what to expect. Before flight, all pilots are required to check for Notices to Airmen (NOTAMs), which inform them of anything unusual that has recently changed at the departure or arrival airport, as well as navigational outages along the way. In practice, NOTAMs contain dozens of notices of varying importance, such as closed taxiways, wet runways, and small, unlit towers miles from the airport. Information about closed runways, however, is critical.

From a human factors perspective, we found that the presentation of information in the NOTAM the crew received did not effectively convey the information about the runway closure. This Air Canada crew missed two warnings about the closed runway at SFO, first in predeparture, and then via datalink before landing. Had they been aware of the closure, the pilots almost certainly would’ve suspected an unusual airport configuration with changed lighting patterns.

The current NOTAM system lists everything that could, even under the most unlikely circumstance, affect a flight. It lays an unnecessarily heavy burden on individual pilots, crews, and dispatchers to sort through dozens of irrelevant items to find the critical and important ones. When an important item is missed—as is common—and a violation or incident occurs, the pilot is blamed for not finding what amounts to a needle in a haystack.

Further, NOTAMs are published in hard-to-read codes. Using plain language and conventional date and time configuration in both local and universal (UTC) time could go a long way toward making flight safety information easier to understand. The Federal Aviation Administration (FAA) has been aware of the NOTAM problem for more than 15 years. In 2012, Public Law 112-153 (Pilot’s Bill of Rights) gave the FAA 1 year to fix the problem. The incident at SFO makes it clear that there is still much more work to be done. This is a safety issue that calls for urgent action.

The fatigue factor. Fatigue continues to be a recurring factor in accidents and incidents. The Air Canada captain had been awake for 19 hours at the time of the incident. It’s estimated that he awoke around 0800 eastern time (ET); the incident occurred at 0300 ET the following day. The captain was not technically “on duty” that whole time, and, under Canadian regulations for reserve crew members, he still could have been available for duty for another 9 hours.

During postaccident interviews, the captain said he did not make a timely incident report to Air Canada’s dispatch after landing because it was “very late” and he was “very tired.” If the captain is too tired to make a phone call to report an incident, should the rules allow him to fly a challenging night approach with the lives of 139 passengers and crew in the balance? If we expect solid human performance where lives are at stake, fatigue rules need to be based on human factors science. The NTSB has recommended that Canada’s fatigue regulations be modified.

Cockpit voice recorders and beyond. The Airbus’s CVR would have provided much more information on what happened, but it was overwritten during the first flight following the incident (current CVRs are only required to store a minimum of 2 hours of audio). Without the CVR data, we may never understand all the reasons behind the numerous procedural failures, but we know one thing for sure: the CVR would have provided a much better picture of just how this incident came close to being a catastrophic accident.

Cockpit image recording could provide a much richer source of critical information. We initially issued an image recorder recommendation as long ago as 2000.

We have had far more success with image-recording technology in every mode of public transportation except commercial aviation. Some pilot groups are concerned about the flight crew’s right to privacy and that the information gathered will be used punitively. Workplace right to privacy has been extensively debated, but for employees in safety-critical positions, privacy should take a backseat to human life.

Unlike written transcripts, cockpit audio and video recordings are protected by federal law and never released by the NTSB. Likewise, video recordings are protected by law from being released. Over-the-air transmissions, such as communications between a pilot and air traffic controllers, are in the public domain, by definition, but in-cockpit audio and video recordings are protected by the NTSB against public disclosure.

More importantly, image recorder data gathered routinely before an accident will be invaluable in preventing the next tragedy. This approach has been highly effective in flight operational quality assurance (FOQA). This approach may pose some technical challenges, but it will significantly increase safety and accountability.

Learn and forgive. One of the best practices used in aviation is the concept of “just culture,” or nonpunitive corrective action. Most people put their best foot forward and attempt to minimize a critical error when they make one, which is perfectly understandable. Yet, some supervisors want to mete out sanctions to “teach a lesson” or to make an example of a crew. Unless someone is habitually error prone or intentionally ignoring safety procedures, a punitive response is completely inappropriate to critical performance environments in all modes of transportation.

This Air Canada flight crew will almost certainly never make such a mistake again, and my hope is that they will continue to fly to the normal end of their careers.

We gain much more from being introspective rather than judgmental about this incident. We should celebrate when someone confesses a mistake and learns from it. This is one of the key factors in the decades-long decline in commercial aviation’s accident rate. Fortunately, we’ll get another chance to put some fixes in place to make a highly improbable event even less likely to recur. Let’s not squander it.

 

Reduce Fatigue-Related Accidents and Expand Recorder Use to Enhance Safety are topic areas on the NTSB 2017-2018 Most Wanted List.

 

Why You Should Buy a Car with Collision Avoidance Technologies

By Amy Terrone, NTSB Safety Advocate

My morning commute into work is often delayed because of a crash. If you live and work in the Washington, DC, area, you know that we have some of the worst, most congested rush-hour traffic in the country, which means a bunch of tired, irritated drivers are on the road at the same time—perfect conditions for a crash. As I passed by one such crash scene recently, I wondered how the driver ended up in that situation. My guess is that he or she was distracted by a cellphone or was traveling too close to the car ahead in the stop-and-go lineup. Unfortunately, these things happen every day.

But did you know that there’s already technology out there that can prevent these types of crashes? Automatic emergency braking, or AEB, is available on many vehicles and is increasingly becoming standard—not just an option included with a luxury package. In fact, 22 automakers have agreed to install AEB as a standard feature by 2022. AEB is designed to address the large number of rear-end crashes in which drivers do not apply the brakes, or fail to apply enough braking power to avoid or mitigate a crash. AEB systems use sensors, such as radar, cameras, and lasers, to detect an imminent crash, warn the driver, and, if the driver does not take sufficient action, engage the brakes.

Forward collision warning, part of the collision avoidance system paired with AEB, helps you react to an imminent crash. It alerts you to the vehicle ahead so that you reengage with what’s happening on the road and apply the brakes.

We’ve promoted the benefits of collision avoidance technologies—also known as advanced driver assistance technologies—since 1995. In particular, we’ve advocated for forward collision avoidance systems featuring AEB and forward collision warning, and we’ve issued recommendations to require such technologies in all vehicle types—not just the ones you and I drive, but big rigs and big buses, as well. Collision avoidance technologies also include other technologies to help a driver avoid a crash, such as blind-spot monitoring/detection, lane-departure assist/warning, and rear-cross traffic alert. We’ve made implementing and using collision avoidance technologies a focus of our Most Wanted List for several years now.

MWL2017-18_03_collision

Technology can compensate for human behavior and human mistakes. Ideally, all humans should remain focused on the roadway 100 percent of the time; however, that’s not realistic. Distraction, impairment, fatigue, speeding, and wrong decisions are all preventable, but they still occur. That’s where collision avoidance technologies come in. Technology can play a key role in reducing the nearly 40,000 deaths that result from human error on our roadways each year.

In 2001 and again in 2015, we released a special report assessing the efficacy of collision avoidance systems and their ability to reduce crashes. A key finding of the 2015 report was that many of the approximately 1.7 million rear-end crashes that occurred on our nation’s roadways in 2012—which killed 1,700 people—could have been mitigated or even prevented by collision avoidance technologies.

Of course, to get the biggest benefit from these technologies, drivers need to understand what they do. Dealers and rental car agencies play a role in educating consumers when we buy or rent a car, but, ultimately, it’s our responsibility to research the technology, request it, and learn how to use it.

Myriad resources can help you ensure you’re equipping yourself with every possible means to prevent a crash, and our Safety Alert regarding rear-end crashes encourages you to do your homework. Two good places to start are the National Safety Council’s My Car Does What website and the National Highway Traffic Safety Administration’s (NHTSA’s) SaferCar website. The Insurance Institute for Highway Safety also announced that it will soon unveil a consumer rating system for advanced driver assistance systems. But, the most often overlooked resource about new collision avoidance technology is your vehicle manufacturer’s website or owner’s manual (yeah, the one you leave in your glove compartment to collect cobwebs). When you’re car shopping, don’t hesitate to ask your salesperson about a car’s safety technology and ask for a demonstration.

The NTSB has recommended that NHTSA rate collision avoidance technologies as part of its 5‑star safety ratings (NHTSA currently recommends certain driver-assist technologies), and advertise the ratings on new-car window stickers. Until then, it’s up to us, the consumers, to do our research.

The technology to prevent common types of crashes is here today and is proven to save lives. So, what are you waiting for?

Observing an Impaired Driving Enforcement Training

By Member T. Bella Dinh-Zarr, PhD, MPH

This summer, I had the opportunity to observe men and women training to be law enforcement officers. Part of their training included 40 hours focused specifically on executing a standardized field sobriety test (SFST).

The SFST is a series of assessments an officer performs during a traffic stop to determine if a driver is impaired. I was surprised to learn how the SFST also helps officers detect drivers who are impaired by drugs other than alcohol.  When an officer encounters a subject who he believes to be impaired, his first response will be to evaluate his physical condition by administering a SFST.  Although all the clues for impairment which are analyzed in the SFST are for alcohol, there are similarities in impairment by some of the 7 different drug classes.  Additionally, the presence of some impairment clues and the absence of others can be a strong indicator of drug impairment.  For instance, a subject who displays nystagmus (uncontrollable twitching of the eyes) from alcohol impairment will also present an inability to maintain balance.  With some drug classes, there will be a high degree of nystagmus, but their balance may not be affected to the same degree.  The same goes with the strong odor of alcohol.  If a subject is obviously impaired but has no odor of alcohol about their breath, drug impairment may have an influence.  When officers administer an SFST to a suspected drug-impaired driver, the results often identify the need for a drug recognition expert (DRE) to evaluate the driver for physical signs of drug impairment.

Trainees learn about the effects of alcohol on the body and the visual cues to look for when they suspect a driver is impaired, as well as how to determine the likelihood of impairment so they have probable cause to administer an impairment test. In addition to the SFST training, officers spend hours learning how to document impaired driving arrests and how to present evidence of such arrests in court.

To effectively practice these skills, trainees conduct the SFST on live subjects who have consumed varying amounts of alcohol in a controlled environment (a law-enforcement training facility; subjects are driven home by law enforcement officers afterward). Volunteers are given measured amounts of alcohol over the course of 4 hours prior to the mock SFST, and then are given a breath test to document their breath alcohol concentration (BrAC) as the evaluation begins. SFST instructors observe trainees as they evaluate subjects and offer real-time feedback and suggestions for improvement. By using live subjects, trainees witness how variably alcohol consumption can present in individuals.

A law enforcement trainee conducts the SFST on a live subject that has consumed alcohol.
A law enforcement trainee conducts the SFST on a live subject that has consumed alcohol

I spent some time with the live subjects, all of whom were impaired, before their evaluations. All subjects had a BrAC of 0.08 percent or higher and, had they been behind the wheel, would have been subject to arrest. The SFST instructor showed me the documented BAC levels of the subjects. While all of the subjects were at or above 0.08, they were each keenly aware that they were in no condition to drive. They were unsteady on their feet, reacted slowly to orders, and struggled to follow directions given by the trainees. I couldn’t tell which subjects had higher BACs than others, but just knowing that some were close to or just above the “legal limit,” I would not be comfortable sharing the road with any of them.

When the evaluations started, I got to be one of the (sober) subjects evaluated by the trainees. I received the same set of questions and was given the same tests as the impaired subjects. The SFST is incredibly thorough, and officers determine the likelihood of impairment by scoring the elements of the test based on how the subject performs. I was asked questions such as, “Where are you coming from?” “Have you had anything to drink tonight?” “Are you on any medications or do you have any medical conditions that I should be aware of?” From there, I was asked to walk a certain number of steps, heel to toe, counting each step out loud; to stand on one foot with my arms at my sides and balance, and to track a pen that the trainee moved in front of my face from side to side. The test is designed to evaluate a person’s ability to complete simultaneous tasks—an ability that is hindered by impairment. What I learned later is that each part of the test helps the officer gather data about the subject—slurred speech, an alcohol odor, impaired coordination, and atypical eye movement are all signs of impairment. Subjects who score in or above a certain range on the test are considered to have a positive likelihood of impairment.

Member Dinh-Zarr undergoes the SFST
Member Dinh-Zarr undergoes the SFST

I learned two things through this test. First, I struggle with balancing on one foot, even when I’m sober! Second, the trainees are taught this protocol very thoroughly; they are instructed to take their time and not rush any element of the test. They need to be very deliberate because officers cannot administer a breath test unless they positively detect impairment.

End Alcohol and Other Drug Impairment in Transportation is on our Most Wanted List of transportation safety improvements. Specifically, we recommend that all states lower their per se BAC limit from 0.08 percent to 0.05 percent or lower. Observing this SFST training exercise reaffirms my belief in the NTSB’s position on this recommendation. A 0.08 percent BAC illegal limit is far too high. At .05, drivers have difficulty with vision, coordination, and steering, even if they may not realize it.  In fact, in 2016, approximately 1,400 people were killed by drivers with a BAC of 0.01­–0.07 percent.

.01 - .07 BAC Fatalities
Driver BAC’s from fatal crashes in 2016. Drivers are not considered legally impaired before 0.08 BAC, but 1,400 people were killed by drivers that had between 0.01 and 0.07 BAC in 2016.

In addition to calling on states to lower their legal BAC limit, we also recommend increased high-visibility enforcement, such as sobriety checkpoints, which allow law enforcement officers to screen a high number of drivers in a short amount of time for potential impairment. All of these safety recommendations are not intended to increase arrests.  In fact. they may decrease the number of arrests because they deter many impaired people from even getting behind the wheel in the first place.  That is true prevention!

Our 2013 report, “Reaching Zero: Actions to Eliminate Alcohol-Impaired Driving” includes a series of recommendations to combat impaired driving. We believe that implementing a combination of a lower BAC legal limit, increased or high-visibility enforcement, and mandatory ignition interlock devices for all DUI offenders can reduce the number of impaired drivers on our roadways. Our goal is to eliminate impaired driving by convincing people to separate drinking or drugging from driving.

I’d like to thank all law enforcement officers who conduct SFSTs and remove alcohol-impaired drivers from our roadways. It may not seem as glamourous as other aspects of their job, but they are making our nation safer with this important work. These trained professionals help keep our roads safe and prevent families from losing a loved one to an impaired driving crash. It’s up to the rest of us to do our part to reach zero.

Back-to-School Safety Series: Eyes on the Road, Hands on the Wheel, Minds on What Matters

By Nicholas Worrell, Chief, Safety Advocacy Division

 Parents and teens, please read this blog together (not while you’re driving!).

Driving fast with a sport carWhen you hear “distracted driving,” you probably immediately think of the endless “don’t text and drive” campaigns across the nation each year. This is not without good reason—texting and driving is certainly one of the deadliest forms of distraction. Reading or responding to a text takes your eyes from the road for 5 seconds. If you’re traveling at 55 mph, that’s enough time to drive the entire length of a football field.

Today’s teens have grown up with near-constant access to social media. Some teens text and drive, even though they acknowledge it’s dangerous. According to a recent AAA poll, 94% of teen drivers acknowledge the dangers of texting and driving, but 35% admitted to doing it anyway. Modern teens are often inseparable from their phones. It’s hard to think of a scenario in which a teen isn’t pulling out a device to text, take a selfie, or access social media. Most of the time, this is a minor annoyance to those competing for a teen’s attention, but this habit playing out behind the wheel could kill someone.

Distracted driving can be as deadly as driving impaired—the law supports this fact. New laws are being implemented across the nation to curb distracted driving; for example, an Oregon law that went into effect July 1st punishes distracted drivers with consequences akin to those incurred by DUI offenders. And, like many of the other topics we’ve covered in our Back-to-School Safety Series—impairment, drowsy driving, and seat belts—“Eliminate Distractions” is on our Most Wanted List of transportation safety improvements.

But what many fail to realize is that distracted driving is more harmful for teens than DUI—teens who text and drive are involved in 6 times more car accidents than their drunk‑driving counterparts, making it statistically even more dangerous to drive distracted than to drink and drive (and that’s saying something, considering the common knowledge that drinking and driving is an often fatal, horrible idea). Distracted driving kills more teens than drunk driving. A 20-year-old’s reaction time while talking on a cell phone is equal to the reaction time of 70-year-old. Texting while driving increases crash risk 23 times over for drivers of all ages. Texting while driving now accounts for 1.6 million crashes a year—that’s 25% of all car crashes. It’s a bigger issue than a few typed words on a little cell phone screen would seem.

As we mentioned in our introductory blog, if children grow up watching their parents drive distracted without major incident, they’ll see the danger as slight and the behavior as acceptable. But what your children don’t know is that whether it’s the first time or the fiftieth, at any moment the statistics can catch up to you. The good news is that 62 percent of teens say they don’t text and drive when their parents remind them not to—so, starting now, remind your kids about the dangers of distracted driving, and then practice what you preach.

Take a moment now and talk about it. Make a family rule on distraction and hold each other accountable.

Ten Years Later: Remembering Chatsworth With Action

By  Member Jennifer Homendy

Ten years ago today, September 12, 2008, a Metrolink commuter train filled with passengers in Chatsworth, California, collided head-on with a Union Pacific freight train. The collision took the lives of 25 people and injured 102 others. The cause: A texting engineer. A human operator making a human error.

On this 10th anniversary, we offer our condolences to all those who lost loved ones or were injured in the Chatsworth tragedy.

 

Photo of the Collision of Metrolink Train 111 With
Union Pacific

Although I was not a Member of the National Transportation Safety Board at that time, I was working tirelessly as the Staff Director of the Subcommittee on Railroads, Pipelines, and Hazardous Materials in the U.S. House of Representatives to mandate implementation of technology, called positive train control (PTC), which could have prevented the Chatsworth accident from occurring.

PTC is designed to automatically stop a train when a human operator fails to. Human error is the leading cause of all train accidents. Frustratingly, the NTSB has been recommending that railroads implement PTC to address human error-caused accidents for nearly 50 years.

In the wake of the Chatsworth collision and a number of others investigated by the NTSB, Congress passed the Rail Safety Improvement Act of 2008, which required freight, intercity passenger, and commuter railroads to implement PTC by the end of 2015. As the deadline approached, Congress extended it to 2018, with the possibility of further extensions until 2020. Now, as the new deadline approaches, PTC is still not fully implemented.

We know from railroad reports to the Federal Railroad Administration, the agency charged with regulating the railroads, that PTC is operational on only a small fraction of the railroad network.

Accidents, however, continue to occur. Since 2008, the NTSB has investigated 22 accidents that could have been prevented by PTC. Together, these accidents have resulted in 29 deaths, more than 500 injuries, and more than $190 million in property damage.

Tomorrow, Chairman Sumwalt will testify on Capitol Hill regarding the need to finish the job without further delay. Regrettably, nothing that the NTSB does can turn back the clock and change a tragic outcome; we can only urge that others be spared such an outcome in the future.

As the newest Member of the NTSB, I will continue to advocate for full implementation of PTC and for the safety recommendations we made as a result of the Chatsworth crash so that a similar tragedy is prevented in the future.

In the meantime, there is something you can do as we remember Chatsworth: eliminate distractions while operating a vehicle. Distraction continues to play a significant role in accidents.

Distracted driving kills thousands and injures hundreds of thousands every year. On the railroads, PTC is an effective backstop in case an operator is distracted, fatigued, impaired, or otherwise unable to take the right action. But operators must still adhere to strict procedures to minimize the chance of an accident.

On the highways, collision avoidance systems—forward collision warning systems and automatic emergency braking—are beginning to play a similar role to PTC. We think that these systems should be on every car, and we are working toward that outcome. But even without a collision avoidance system, you can take control by doing the right thing. Don’t send a text, make a call, or update your social media while driving. Strict laws aimed at preventing the use of portable electronic devices while driving and high-visibility enforcement can help, but ultimately, it’s up to each driver to drive attentively.

As we mark the 10th anniversary of the Chatsworth collision, we still have a long way to go to ensure the same kind of accident doesn’t happen again. But there are things we can do. We can insist railroads complete PTC implementation on all their tracks. We can choose vehicles with collision avoidance systems, and we can refuse to drive distracted.

Fatal collisions don’t end on impact; they echo through communities for years after the moment of a crash. But there can be hope as well as mourning in the echoes—hope for change that will prevent future tragedies. It will take all of us in transportation—professionals and the general public—to ensure the lessons learned from the Chatsworth tragedy result in that change.

 

The Value of Video

By Jennifer Morrison, NTSB Investigator-in-Charge, Office of Highway Safety

 On January 19, 2016, a Greyhound bus with 22 people on board was traveling on a California interstate in the dark in moderate-to-heavy wind and rain. The driver intended to take the left exit, en route to the next stop in San Jose, but instead crashed the bus head-on into the end of a concrete barrier. The bus jumped the barrier and rotated onto its side. Two passengers were ejected and died; the driver and 13 passengers were injured.

The crash occurred at 6:37 in the morning, after the driver had been on duty, commuting to his route and driving the bus, for about 12 hours. Tempting as it was to assume this crash resulted from driver fatigue, our investigation soon revealed that other factors were at play.

HWY16MH005_prelim[1]
Final rest position of bus and remains of REACT 350 crash attenuator base
When I arrived on scene with the rest of the “go team,” we discovered that the highway interchange where the crash occurred had four through lanes, two right exit lanes, and a single left exit lane. When the driver moved the bus left to what he thought was the left exit lane, he instead unintentionally entered a 990-foot-long unmarked gore area that separated the through lanes from the left exit lane. The gore area ended at the concrete barrier where the crash occurred. The crash attenuator at the end of the barrier likely absorbed some crash energy, but it was not designed to redirect a large commercial vehicle like a Greyhound bus.

What was interesting about the crash attenuator was that it had been hit before; our investigation found that damage from the previous impact had ripped the reflective sheeting off its face. Records showed that the California Department of Transportation had placed temporary barricades but had never finished the repair.

Fortunately for our investigation, the bus, like most of Greyhound’s buses now, was equipped with a video camera system. Video recovered from the bus showed that the temporary barricades had blown over, possibly in the wind and rain that morning. As we watched the forward-facing and inward-facing videos, the scene became clear: the driver was attentive as he signaled and moved into the gore area, interpreting it to be a travel lane. At 1 second before impact, a dark black barrel (the first part of the crash attenuator) appeared in the middle of the “lane” (see Figure 1). There was no reflective sheeting on its face, and there were no temporary barricades set up to identify the hazard.

Without the video camera system onboard the bus, it would’ve been impossible to know that the barricades had blown over prior to the crash, rather than simply been displaced by the event. Without the video evidence, it would have been easy to assume that the driver was just too tired or otherwise distracted by fatigue to see the warning. But the video showed clearly and indisputably the events leading up to the crash.

greyhound video
Still image of onboard video at 1 second prior to impact.

Onboard video systems provide investigators and fleet owners with the invaluable, unbiased evidence to interpret—and work to prevent—crashes like this one. That’s why we’ve strongly recommended they be installed on all highway vehicles for decades. We even emphasize the importance of these systems on our Most Wanted List of transportation safety improvements. This crash illustrates why this technology is important, and we continue to urge operators to install it across their fleets.

NTSB Most Wanted List of Transportation Safety Improvements 2017-2018

To learn more about this issue, join us Thursday, September 13 at 2 PM EST, for our “Reducing CMV Crashes Through the Use of Video Recorders webinar.” In our 1-hr webinar, NTSB Member Bella Dinh-Zarr, investigators and recorder analysts from the Office of Highway Safety and Office of Research and Engineering, along with commercial fleet owners representing the truck and bus industries, will discuss why and how their organizations use video recorders to improve safety. NTSB investigators will provide an in-depth discussion into the Greyhound crash discussed in this blog and will also highlight a truck case study. For more details or to register, visit this link.